Provider Demographics
NPI:1184813974
Name:NICHOLSON, PHILIP LEROY (OD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:LEROY
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17904 GEORGIA AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-2239
Mailing Address - Country:US
Mailing Address - Phone:301-595-9041
Mailing Address - Fax:
Practice Address - Street 1:10925 BALTIMORE AVE
Practice Address - Street 2:OPTICAL DEPARTMENT
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-2117
Practice Address - Country:US
Practice Address - Phone:301-595-9041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1322152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDU57138Medicare UPIN